The American Opioid Epidemic 20XX: Dropping the H-Bomb

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Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

I should preface this by saying that I'm a doctor in an inner-city clinic in Western Canada. Although I'm a family doctor by training, the nature of my clientele means that I spend about half my time dealing with either addiction, chronic pain, or both. We have an explicit harm-reduction focus, and run opioid maintenance programs in addition to a needle exchange.

I prescribe a fair amount of both methadone and buprenorphine for opioid maintenance - of them, I much prefer buprenorphine since it seems to have so much less sedation than methadone, in addition to not interacting with other sedating meds to the same degree as methadone. The opioid blockade, and the ceiling effect, also help with the safety margin. However, buprenorphine (suboxone) has a crap reputation on the street - 'that poo poo doesn't work, I don't want to try something new, how dare you make me a guinea pig etc. etc.' My distinct impression is that people with opioid dependence issues who are ready to get better do well on suboxone, and people who aren't ready to quit... do not. Has anybody in this thread had experience with both? This thread is fascinating to me because even though I have a ton of patients with opioid dependence, very few have been able to articulate their experiences like people in this thread.

Also, how is the US doing with harm reduction policies these days? My clinic is part of a group trying to get safe injection sites set up in my city, which I'm pretty sure (from research in Canada as well as in Europe) will reduce mortality as well as morbidity. Any active safe injection sites south of the border?

jet sanchEz posted:

Canada has a fentanyl problem

http://www.theglobeandmail.com/news/investigations/a-killer-high-how-canada-got-addicted-tofentanyl/article29570025/

How Canada got addicted to fentanyl

Manufactured in China, it easily crosses our porous borders, triggering a heroin-like bliss in users � and, all too often, death. The Globe investigates the rise of a fatal opioid

Buyers are assured their package won�t get seized at the Canadian border. To avoid the risk of detection, says a supplier from China, he conceals the purchase alongside urine test strips. Not that there�s reason to worry: Canadian border guards cannot open packages weighing less than 30 grams without the consent of the recipient.

The supplier, who identified himself only as Alan, says he has two customers in Canada. He e-mails photos of fentanyl hidden inside silica-desiccant packets � the type normally used when shipping goods such as electronics � and a screen shot of a recent order from Canada, including a shipping address for a clothing store in British Columbia�s picturesque Okanagan Valley.

Yeah, fentanyl kind of came out of nowhere in the last few years. It's weird, but the crusty old addicts that I treat rarely if ever use the stuff. Certainly there's less overdosing, but I'm not sure if they're experienced enough to feel when there's a problem or if it's because we try to give as many people as possible take-home naloxone kits or whatever. Most of the fentanyl deaths in Alberta (about 2/3 according to one public health doc I know) are in suburban settings; one of the nurses at my clinic had a son pass away from fentanyl, which was apparently one of the first times he'd tried any drug which wasn't pot.

# ¿ Apr 9, 2016 21:59

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# ¿ May 13, 2024 21:17

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Asproigerosis posted:

I meant in the USA, there aren't any safe injection sites and I'm sure the attempts to start it up in New York and California will be stomped to bits as soon as it gains enough traction for media to start crying about taxpayer funded drug dens.

Grundulum posted:

Which makes no sense to me. If addicts are provided free drugs, doesn't that eliminate the incentive to steal to pay for the next hit? You'd think the same population crowing about taxpayer-funded drug dens would love a reduction in crime. Actually, you'd think everyone but the prison system would love a reduction in crime.

There's a distinction between 'safe injection sites' and 'opioid-assisted treatment'. A safe injection site (at least as structured in Canada) only implies a location where you get clean needles and a nurse observing you while you shoot up. It does not involve freely provided drugs; Insite is a BYOB model. This reduces the harm from injection - you're less likely to get cellulitis if you have clean tips and alcohol swabs - but since you're still injecting gently caress knows what there's still a risk from the drugs themselves.

Unfortunately it's a lot harder sell to allow prescribing drugs for the express purpose of injection. It would reduce the harm from injecting fentanyl or prescription drugs not intended to be injected, and there's good experience in Europe and a well-designed study in Montreal involving providing heroin to addicts, but at present it's kind of a 'lose your medical license' bad idea. I'm... working on that, but I don't hold out a ton of hope.

The_Book_Of_Harry posted:

I am currently succeeding in methadone-assisted treatment, and I have used both bupe and methadone extensively.

Methadone succeeded where bupe failed, not because of the actual drug, but because of the forced compliance. I have to show-up every day to take my methadone, whereas my suboxone prescription simply handed me 105 pills and said, "see ya next month!"

My methadone clinic stresses participation in both individual and group therapy, and I see an outside psychiatrist. On bupe, I sometimes went to see a psych doctor, and I never attended any groups.

Many people will sell a portion of their bupe to buy dope for a few days every month...if they can even manage that much self-control. On methadone, I am subject to a minimum of one drug-screen every month, and testing positive eliminates take-home medication. Methadone is also slightly less street-sellable. Exceedingly few people take it for any other reason than avoiding sickness.

Bupe's blockade effect is very easy to shoot-through, as well. Oxymorphone and hydromorphone can be injected effectively with little diminished effect. In contrast, I've wasted a good chunk of money and time trying to get acceptably high while on methadone...to no avail.

Thanks, this is really helpful. I had always thought that the buprenorphine blockade was far stronger than that of methadone (based on the relative mu-receptor affinity; buprenorphine is stronger than pretty much anything including fentanyl) - perhaps it's dose-based? Most of my chronic opioid users are on 12-24 mg of suboxone; was the shoot-through at a lower dose?

Buprenorphine is as strictly regulated or more than methadone in Canada; based on your report maybe that was a good idea. I prescribe it daily observed until there's substantial evidence of stability and multiple months of clean urine drug screens at random times, and even after years there's gotta be a very good reason for me to allow more than a week of carries at a time.

# ¿ Apr 12, 2016 06:36

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

pangstrom posted:

Albino Squirrel what proportion of your maintenance patients would you estimate have gotten off opiates, sub-setting however you want to (within X years, or among those who really wanted to, etc.)?

Maybe 5% have tapered off and are opioid free, in the seven years I've been working here. About half have either been lost to followup or have relapsed with street opioids. The rest remain on maintenance treatment with varying degrees of sobriety.

Bear in mind, though, that I have a unique patient population; most are either homeless or recently have been. A very large number are schizophrenic. Most are using multiple drugs. The rate of PTSD approaches unity.

In 'regular' practice many more patients successfully discontinue maintenance treatment. Still, people can be on it for decades and lead relatively normal lives, so I'm never in any rush to discontinue treatment.

# ¿ Apr 13, 2016 00:03

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

PT6A posted:

Police and media are currently busy freaking out about something called W-18 here.

http://www.vice.com/en_ca/read/everything-we-know-so-far-about-w-18-the-drug-thats-100-times-more-powerful-than-fentanyl

Is this a legitimate risk, or just a case of the media trying to freak out about something?

Welp, large amounts (like kilogram quantities) have been seized. So it's definitely out there. The scary thing for me is that it apparently binds to the opioid receptors even stronger than Narcan. So there's effectively no antidote.

W-18, ironically, was invented at the University of Alberta in the 70s and then promptly shelved as there was no possible clinical use for it. So it's kind of poetic justice that it's now a part of our opioid epidemic.

# ¿ Apr 23, 2016 02:19

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Fun thing about street value: Tylenol #3s go for a couple of dollars a pill up here. Generic acetaminophen/codeine pills of the same strength go for about a dollar. And codeine 30s go for about 50 cents.

It makes no sense to me, because it's the same amount of codeine in each pill. I presume there is some pain benefit to the acetaminophen (and it probably predominates if you're opioid tolerant) but it doesn't explain the 'brand value' of T#3s.

I make it a point to usually prescribe codeine pills, partly because I don't want people overdosing on acetaminophen (which is a horrible death), but also because I don't want my patients selling their pills for coke.

# ¿ Apr 27, 2016 17:17

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

PT6A posted:

I just got a wisdom tooth out (normal extraction with no complications under local anaesthetic) and I was offered Tylenol 3 for the post-extraction pain. I didn't take it, opting instead for Ibuprofen, and I haven't even taken those as much as I theoretically could because there's very little pain (I'm taking it twice daily, mainly to reduce inflammation, instead of 4 times per day).

If people are being prescribed opiates for this level of "pain" which amounts to a slight stiffness in my jaw, I'm not particularly surprised we have an addiction epidemic. I have a lovely pain tolerance, too.

Now, if they gave me some anxiety meds to deal with my constant concerns that I'm going to be careless and dislodge the clot and get dry socket, I'd not say no.

Different people have tremendously different pain thresholds, in addition to very different responses to different medications. About 5-10% of people, for instance, are unable to metabolize codeine into morphine and hence get essentially zero benefit from Tylenol #3s (except, of course, from the acetaminophen). So while ibuprofen does cover most people for wisdom tooth extraction, it's reasonable in some cases to go into the lower-grade opioids such as codeine.

I got Tylenol 3s after my wisdom tooth extraction; didn't do a drat thing for my pain but it did make me puke all over my parents' minivan.

Also learn from my mistakes, don't have nachos for a few months.

PT6A posted:

Asking for money from a friend/acquaintance would seem to be a more effective way of getting drugs than to ask a doctor to do something outright illegal, though. I'd rather give an addict money than risk my own freedom by actually supplying the drugs. Of course, I'd probably try to avoid either one.

You're presuming they haven't already tried asking for money. And most psychiatrists don't prescribe opioids, but a few get into addiction management and rarely some specialize in pain management.

Guavanaut posted:

That's also where it gets ethically difficult in terms of terminal illness though. What do you do when someone is at a state where it's arguably true that getting an extra hit of IV diamorphine is beneficial from a whole-life suffering point of view compared to being fed?

See, the problem here is that we've been conditioned to think of this as a zero-sum game. It's relatively easy to give someone a dose of an opioid replacement so that they don't go into withdrawal, and even moving to prescription IV opioids in certain circumstances (Switzerland, for instances, uses a lot of prescribed heroin) can stabilize them. And it's cheap - like, pennies a dose. So the solution is that we prescribe the patient some suboxone (or hydromorphone, maybe) and then they can go use their money to buy a sandwich.

# ¿ May 29, 2016 05:11

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

PT6A posted:

Hadn't thought of that, I was just in a dental office so I would've had to go to a pharmacy to fill an actual prescription anyway.

Even in an outpatient situation, the general rule is to prescribe the painkiller that is usually required; although your patient could come back to ask for more powerful painkillers, it's an inconvenience for both them and the prescriber (also, they're in pain until they get the new drugs).

Although your point is taken about common procedures getting a bit of an over-call in terms of painkillers, and I think there's a move in dental surgery to go from opiates to non-opiate management of routine procedures like wisdom teeth.

# ¿ May 29, 2016 19:50

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

dethkon posted:

It was. What teenager is going to turn down a free high, Doctor approved? It was the most profound drug experience I ever had at that point. Looking back, I wouldn't be surprised if he was a drug "enthusiast" himself.

Oh man, anaesthesia attracts the enthusiasts like you wouldn't believe. One of my surgeon friends had to go searching for the anaesthetist because they couldn't find him for the start of surgery, only to find him in the OR bathroom, unconscious and tied off with a needle in his arm.

Interestingly, when you gently caress up and have to go into rehab as a doctor, there's something like a 90% success rate in maintaining sobriety. I think the difference between that and the general population is that a) there's immediate access to inpatient treatment which tends to last longer than publically-funded rehab; b) there's frequent and random drug testing to keep you honest, and c) the College holds your very lucrative career in the balance if you relapse.

# ¿ May 30, 2016 16:52

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

OneEightHundred posted:

Saw something recently on this saying that a large problem is just opiate painkillers being prescribed for too long, and some new recommendations came out that they shouldn't be prescribed for more than a week. I don't know what the typical dentistry experience is, but I got 30 days of hydrocodone/APAP after getting my wisdom teeth out. I switched to 600mg ibuprofen after 2 days and was off painkillers after a week. So that's 23-28 days of unnecessary pills.

My professional, medical opinion is that that is a loving retarded dose for wisdom teeth.

# ¿ May 30, 2016 17:48

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Subvisual Haze posted:

The CDC's new recommended guidelines on opioid prescribing are really good. They're so good that I wish a lot of their points weren't just recommendations, but actually had some legal limits to reinforce them. http://www.cdc.gov/drugoverdose/pdf/pdo_checklist-a.pdf

Be careful what you wish for. We have similar guidelines in Canada; our 'watchful dose' for opioids is 200 mg morphine equivalent as opposed to 50/90 per this American guideline.

The problem is that the First Nations and Inuit Health Branch (FNIHB), the organization which provides medication coverage to Canada's native people*, considers 200 mg to be a limit and is lowering coverage stepwise; it'll be a hard cap of 200 mg coverage by later this year. So even if you need to prescribe 250 mg - say, in someone whose previous doctor had foolishly upped their dose - you can't. The 'watchful dose' is supposed to trigger you to consider red flags, look for alternate medications, and refer to specialists if necessary, not be an absolute limit to the amount of opioids you can prescribe. I know this because one of the doctors I share an office with was one of the people who wrote the guidelines, and that's what she loving told me.

Setting hard legal limits on medical care isn't great, because there are ALWAYS exceptions, and my career is based on treating those exceptions. There's also nothing in the guidelines about some fairly simple protective measures, like limiting people's medication to once-weekly or even once-daily pickups; in my experience that goes much further in preventing overdose than many other measures. Also, suggesting a referral to a pain specialist at >90 mg of morphine seems really low, unless pain specialists are much more available and have quicker referrals in the US than in Canada.

*based, incidentally, on the 'medicine chest' provision in the treaties in which the local first nations people ceded land in the West. This has been interpreted to mean 'we will pay for your medicine,' and now we have a barely-functioning government department that does that!

# ¿ Jun 3, 2016 15:29

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Spoondick posted:

I may be wrong about the impending prescriber apocalypse. The problem is so pervasive that if you withdrew every medical license over inappropriate opioid prescriptions we wouldn't have many doctors left to practice afterwards. That fact may be the only thing that gets these shitheads off the hook, but I'd still like to see them aggressively prosecute doctors who've already had their licenses taken. I mean look at this goddamned poo poo and tell me it isn't murder.

I don't know if that's homicide, if only because there's no clear intent to harm the patients. It is criminally negligent practice, however. "This guy reported he had a two week prescription of oxycodone stolen. I'll give him 50 days this time! :downs:

"

It's not the worst I've seen, either; I wound up seeing someone whose previous family doctor had him on a combination of weekly oxycodone and 500 dilaudid 8 mg a month, 'for breakthrough.' His oral morphine equivalent dose was 4464 mg a day. FOUR THOUSAND FOUR HUNDRED AND SIXTY FOUR MILLIGRAMS. My new rule is that if you have more opioids than salt in your diet, you almost certainly have a problem.

It's going to continue being a problem until a) pain management and addiction are taught, and taught well, in medical school and family medicine residencies, and b) the croakers either retire, die, or are imprisoned.

# ¿ Jun 4, 2016 15:52

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Spoondick posted:

Yes. Those tricky addicts hoodwinked all these unsuspecting doctors into writing them lethal prescriptions. If only doctors were given some sort of training on how to determine if a patient requires treatment or not and how to provide treatment without killing patients. If only there were resources they could utilize to independently and objectively verify their patients clinical histories. If only these doctors didn't have to book 45 patients and take on 30 more walk-ins every day to make 7 figures a year. If only... we could have saved so many lives. Granted, addiction therapy in America needs a shitload of work and it's difficult for people suffering from addiction to get competent help. But. You sure as gently caress aren't helping by giving addicts exactly what they want, free of charge, plus refills. We tried that. Hundreds of thousands are dying. I'm not convinced an addict is better off with a doctor than a street dealer given the number of people prescription drugs are killing. The most insidious aspect of the whole thing is that a lot of prescription drug addicts either don't realize how addicted they are or feel safe or legitimized in their addiction because they're assuming that since their doctor is a trained professional their dosages and medication combinations must be safe, when in fact their doctor isn't paying attention because they don't give a flying gently caress if their patients live or die.

I've been on the frontlines of this bullshit for 10 years now. You know what you say when someone asks you to do something you objectively know is unethical or illegal? No. You loving say no. You say no a lot. I've said no to tens of thousands of people. You know how many of them have gotten me in trouble or ruined my reputation? Not a single loving one of them. Everything goes to poo poo if you don't say no.

I agree with most of what you're saying, except your implication that doctors are given adequate training on how to manage opioid use. They really aren't. The amount of teaching I got on pain management, and on addiction treatment, was essentially zero. I finished residency in 2008 and I don't think the formal teaching has improved much, though I'll ask the med student at work this week.

And saying "no" is a skill. It's a tough one for most doctors to learn because it's so different from everything else you're taught; the current focus of medical education is 'patient-centered care', in part to prevent us from turning into uncaring autists unless you're a surgeon. It can be a bit jarring to switch from being solicitous of what meets a patient's needs to telling them to gently caress off when they request a month of PRN dilaudid. Not that you don't have to say no - you absolutely loving have to - but it's a skill and one that should be taught early in the education process.

# ¿ Jun 7, 2016 14:36

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

jabby posted:

B) it's easy to say no in these days of patient satisfaction based reimbursement

Side note: Satisfaction based reimbursement is probably the worst idea currently being implemented in medicine, and I don't know how you guys south of the border put up with that bullshit.

# ¿ Jun 7, 2016 14:42

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

ToxicSlurpee posted:

Isn't it also a common problem that people who don't get the answer they want from their current doctor just switch doctors?

I seem to remember reading things about morbidly obese people switching doctors until they get somebody that just doesn't mention it or people who didn't get the meds they wanted switching until they did. Yeah one doctor can say no but what if there's one that will prescribe whatever you want?

Then word gets around and the only way to get enough patients to maintain your practice is to hand out opiates like candy.

Doctor shopping is a problem, because there's always some idiot who's willing to give a patient all the candy they want. The end result is that all the addicted and abusing patients filter on down to the croaker. That's why you're supposed to check your local database to ensure your patients aren't getting a bunch of opioids from said idiot.

There is no risk to your practice in saying no, however. There is always more than enough work to go around. And the majority of patients aren't on opioids, so if word gets around that you're a tightass with opioids and benzos then your days suddenly get much more pleasant.

# ¿ Jun 7, 2016 16:50

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

smg77 posted:

Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer.

People will use the most surprising things to get high. There's been an outbreak of bupropion injection out west for a while now; I'm not sure what the high is supposed to be but maybe it'll help with the smoking? :shrug:

Also, apparently oxybutynin is the new hotness in jail, presumably because if the hallucinations. I did have a patient inject it into his jugular vein once, but to be fair he thought it was related to oxycodone.

# ¿ Jun 9, 2016 17:45

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Ytlaya posted:

I'm prescribed a pretty high dose of Gabapentin, and I'm not sure how anyone could use it recreationally like that. It does have a noticeable potentially recreational effect the first couple times you take it (sorta like some strange mix between xanax and marijuana, but far weaker and only really affects your body), but it stops doing that after the first one or two doses and higher doses don't really have any additional effect past a point, so I don't see how it could be used regularly in that manner.

Gabapentin (and Lyrica) responses vary hugely from person to person. Some it makes high as hell, some it just makes sleepy.

# ¿ Oct 19, 2016 22:14

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

pangstrom posted:

That (along with a similar compound) is the stuff the Russians pumped into the theater to resolve a hostage situation in 2002
https://en.wikipedia.org/wiki/Moscow_theater_hostage_crisis
not a terrible idea if they had given everyone naloxone afterwards but they didn't so lots of people died

Carfentanyl apparently has even stronger binding affinity to the opioid receptor than naloxone. You can reverse the carfentanyl OD, but you need, like, a LOT of Narcan.

# ¿ Dec 18, 2016 20:10

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

The_Book_Of_Harry posted:

According to the warning signs posted at my methadone clinic, narcan can (sometimes) pull a person out of immediate withdrawal, but it wears off pretty quickly. Therefore, narcan will wear off before the carfentanyl has been sufficiently metabolized by the patient. You are likely going to need to hit them with narcan more than once, over (very roughly) an hour/two period.

People have thought their lives had been saved, only to soon drop into that final nod.

This isn't even specifically with carfentanil; naloxone has a shorter half life (at 30-80 minutes) than most opioids; morphine, hydromorphone, oxycodone and fentanyl all have half lives between 2 and 4 hours. (Methadone and bupe have very long half lives of over a day, which is why they work as once daily meds.)

Which is why you ALWAYS send people to the hospital after you revive them with Narcan.

PubMed tells me carfentanil has a half life of 7.7h so in addition to being stupid powerful it also lasts forever. It's like it's specifically designed to murder addicts.

# ¿ Dec 19, 2016 03:38

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

So, in my part of Canada every opioid prescription (except for codeine and tramadol) requires a triplicate prescription. In my case I will generally tape the triplicate to the actual prescription and fax the whole thing in to the pharmacy. One of my colleagues had his prescription pad stolen, but fortunately it got caught pretty early because the patient in question tried to fill a script for "1 pound mophine [sic]".

I was on call and the pharmacist called me to have a laugh about it, and to 'confirm' that that's the prescription we meant to send. "Oh, sorry, I mean four hundred and fifty-four thousand milligrams."

# ¿ Jan 21, 2017 20:11

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Subvisual Haze posted:

I once had a patient in my pharmacy who was on chronic Hydrocodone-APAP at a fairly high scheduled dose (but not extremely high). She expressed to her PA that she would like to lose weight so her PA prescribed her Contrave, an exciting new weight loss medication that he must have heard about in a commercial. Contrave contains bupropion and naltrexone as its active ingredients. Naltrexone blocks opioid receptors. This was the same PA who was prescribing her Hydrocodone.

The initial response I got back when I contacted the PA's office was that the patient was supposed to take both medications because "the hydrocodone is to treat pain, and the Contrave is for weight loss". I luckily was able to convince the patient herself that taking a combination of pills that directly oppose one another wouldn't be a great idea.

I can't be too harsh on the PA though, at least they called me back within 24 hours. Most doctor's offices I try to call about dangerous drug interactions seem to only respond 3-5 days later after multiple calls to MAs and refill nurses, left voicemail messages and faxes. Or instead of returning my call they "respond" by generating an updated prescription...which they'll regularly send to a completely different pharmacy. Many of these prescribers work in the same healthcare system as myself.

Look, the naltrexone blocks the hydrocodone, which gives her withdrawal, which gives her the shits, which leads to weight loss! What's so hard to understand here buddy!

As a side note, if someone is on chronic acetaminophen + an opiate, after a while the entirety of the analgesic effect comes from the Tylenol. The opiate is just so they don't go into frank withdrawal.

# ¿ Jan 22, 2017 01:37

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

I would blow Dane Cook posted:

How well do doctors respond when the pharmacist calls up and says hey you hosed up.

I mean I take it well but I try not to have an ego about it; I'd be a bit more bothered if my patient was harmed by my prescription.

# ¿ Jan 22, 2017 07:05

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

AA is for Quitters posted:

People also don't realize that they can pay some taxes to the ACA and see people get treatment, or they can pay a gently caress ton more in taxes to have the court system pay for treatment, since there isn't enough room in jails for drug offenders, they instead get to go to halfway houses and treatment on the states dime anyway. It just costs more because there's a lot more overhead with court ordered programs versus voluntary treatment.

poo poo, man, that's most social programs. It costs upwards of $100K to 'keep' someone homeless in terms of justice, policing, health care, emergency shelters etc.. Versus about $12K a year to just give them an apartment.

# ¿ Jan 25, 2017 03:50

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

KingEup posted:

Most doctors are not drug policy experts and as many people in this thread have already pointed out, have not received any training in addiction medicine and don't even realise that people can form addictive relationships to Tramadol. I mean how the gently caress did they swallow the bullshit from Purdue that Oxycontin was someone less prone to misuse in the first place? The idea of non-addictive drug that produces euphoria is as absurd as the idea of a non-flammable liquid that is easy to ignite.

See, this is my issue with your line of argument. You've been stating that prescription habits weren't a cause of the opioid crisis, and citing old data that states that iatrogenic drug addiction during treatment for pain is rare, when newer data (and, in my case, copious anecdotal experience) indicates that that is NOT TRUE. You're also pointing out right here the very real fact that oxycontin is hella addictive. And the initial point of access for people was... doctors! Who probably should have been more careful about opioid prescribing for pain!

If you're finding that people are arguing with you, it's because you're inconsistent here.

KingEup posted:

The steps that need to be taken to reduce the harms of opioid addiction are as follows:

Decriminalise all forms of non-medical opioid use. It shouldn't be a crime to make poor health choices.
Fund needle and syringe programs and distribute equipment far and wide.
Give out naloxone kits for free and offer free naloxone administration training for the families of opioid users.
Offer free opioid substitution therapy including Heroin Assisted Therapy.
Fund supervised consumption rooms where people can take drugs with staff on hand to help them if needed.
Repeal opium prohibition

The best part is, I agree with pretty much all of these points! I would add that opioid substitution therapy needs to be much more widely available; we have a couple of very useful drugs in methadone and buprenorphine so that people can manage their cravings and get back to their life. There's a substantial wait list where I am, which is rear end-backwards; you need to strike when the iron is hot and start people on OST when they're ready, but before they relapse.

If they're not ready for traditional OST then harm reduction helps tremendously. For my part I work at a clinic that provides free needles, as well as naloxone kits. We're working on getting a few safer injection sites set up in my city.

# ¿ Jan 28, 2017 16:08

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

The other thing I'm looking into is hydromorphone-assisted treatment. Kinda like heroin-assisted treatment but bear with me here.

For years, doctors in Europe (mostly Switzerland and the Netherlands) have been prescribing injection heroin so that people don't have to go buy it on the street. And it makes sense from a harm reduction perspective; you're only reducing so much harm by providing people clean rigs and a place to inject, if what they're injecting is 'heroin' from the street (usually fentanyl these days, cut with gently caress knows what). There's only one clinic routinely providing heroin-assisted treatment in North America to my knowledge, and that's in Vancouver.

Now, there have been a couple of studies in Canada. NAOMI showed that prescription IV heroin is roughly as effective as methadone in reducing street drug use. They included a small hydromorphone arm for 'validation purposes', which showed that hydromorphone was as good as heroin, and that the participants couldn't tell the difference. SALOME repeated the trial, but with a much larger hydromorphone arm, which confirmed that HM is about as good as heroin. And it makes sense! Hydromorphone is roughly the same potency as heroin, as well as being much more widely available - your aunt on facebook who bitches about how we're coddling junkies probably had IV dilaudid when she had her gallbladder out.

So I'd argue if we're going to proceed with prescribing opioids for IV use, we should probably go with one which is already available, has a much greater degree of prescriber comfort & familiarity, and doesn't have nearly the same stigma. It's a lot easier to sell 'I'm prescribing intravenous hydromorphone in a controlled environment for the purposes of reducing harm and controlling opioid dependence,' compared to 'I AM LITERALLY PRESCRIBING SMACK.' At least in more conservative environments than the Left Coast.

# ¿ Jan 28, 2017 18:52

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Mr Luxury Yacht posted:

If you're talking about Insite they only provide safe, supervised injection, not drugs. It's still whatever the person brings in from the street.

However it's still a hell of a lot safer for them when that Heroin they thought they were injecting turns out to be Fentanyl since they're now surrounded by nurses, doctors, and a pile of Naloxone.

No, Crossroads. Separate clinic. They prescribe pharmaceutical diacetylmorphine.

And yes, physicians do have a responsibility to limit the risk that people become harmed by their prescriptions. That's... is that really up for debate?

# ¿ Jan 29, 2017 01:47

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

The_Book_Of_Harry posted:

Huh?

That article doesn't mention methadone, and hydromorphone isn't diamorphine.

I'm fine with heroin replacement therapy as a tool for reducing harm, but alternatives like bupe and methadone are desirable for a person like me due to their lengthy half-lives. I can miss a clinic day without any fear of experiencing withdrawal symptoms...symptoms I'm likely to treat with street dope.

Oh, God, methadone and bupe are so much better for opioid dependence. If you really wanna get your life back on track that's the way to go. But not everyone does well on them, usually of they're not quite ready to give up the needle. (One of the inclusion criteria for NAOMI was having tried and failed methadone, for instance, which is about 50% of initial methadone scrips.)

Hydromorphone-/heroin-assisted treatment, and more generally safer injection sites, should be looked at as a transitional stage between street use and opioid substitution therapy. It might be a long-rear end transition, but the eventual goal is to get someone on the much better treatments that exist.

# ¿ Jan 29, 2017 22:55

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Ytlaya posted:

This is only tangentially related to your post, but one issue I had on suboxone that I always thought was strange is that one dose a day would not work well for me, and I had to split the dose and take half in the morning and half in the evening. I would begin to experience noticeable withdrawal symptoms by the evening if I took a dose in the morning (not terrible, but enough that I felt too bad to enjoy doing anything and wouldn't be able to sleep by that night). My doctor wouldn't believe me about this. I tried to convince myself it was psychological, but after trying to force myself to just take it once in the morning I realized it definitely wasn't.

Do opioids (and other drugs I guess) affect different people for different amounts of time or something?

Short answer: yes. There is an enormous amount of interpersonal variability in opioid potency and metabolism time. And we're only just now starting to understand that.

With buprenorphine, the half life is generally 24 to 36 hours, but it can be more or less. More importantly, the analgesic window (where it kills pain) is a lot shorter than the window where it relieves cravings. If I use bupe for both pain and dependence I frequently split the dose into equal chunks every 8 hours.

# ¿ Jan 30, 2017 01:58

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

call to action posted:

If overprescription and addiction due to medically prescribed opiates is the issue, why do opiate addiction rates trend nearly perfectly with indices of economic distress? Are poorer people simply in pain more often?

There is actually a greater risk of chronic pain issues in impoverished populations due to a) higher trauma incidence, b) more job-related injuries in manual employment, and c) higher degree of emotional distress which can lead to increased pain perceptions. Also remember that's reported addiction issues; someone with more financial and social resources may be more able to compensate for their addiction issues and so may be less likely to show up in the data.

More importantly, over prescribing is merely one of many contributing causes to the current opioid crisis. It's not the only one, nor is it the main one.

# ¿ Jan 31, 2017 00:48

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Nissin Cup Nudist posted:

Standardized dosages of heroin already exist. Its called Morphine Glibness aside, no. Heroin is just too drat strong of a drug for that to work. If you want a weaker dose, grab morphine. But your body will catch up and you need more and the cycle continues. Someone at work theorized that coworker went to the dosage he used when he was an addict, but his body couldn't adjust after being clean for so long.

There are some drugs where I think an OTC standard dosage would work. Heroin is not one of them.

Heroin is only about 2.5x as strong as morphine; hydromorphone is 5x as strong and we use that all the time. There's nothing wrong with diacetylmorphine as a molecule, relative to other opioids; any objection to it is more about the optics than anything else. That being said, the optics are bad enough that I don't like the option of prescription heroin when hydromorphone exists, and it's a drug that physicians are much more familiar with.

It is a huge problem when people return to old doses after time away, though. That's part of why people are so much more likely to die of an overdose right after getting out of prison.

# ¿ Apr 20, 2017 06:18

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

tetrapyloctomy posted:

Sadly, not approved for use in humans.

Honestly, unless a carfentanil bomb lands in The Tracks in the middle of the night, we're okay -- most people are pretty easy to intubate and only once have I had no vents left (and that was brief). Generally speaking, the biggest problem with naloxone is that it's too effective with the run-of-the-mill overdose. At some point people decided to slam in 2mg with anyone who needed to be reversed, when the actual initial dose is one-fiftieth that. But hey, it comes in 2mg vials for a reason, right? And then you have people barfing and crapping all over the place (I once opened a door to a room and saw a ninety-pound woman in her early twenties stand up on the bed, bend over, pull up the back of her gown, and spray liquid poo poo on a wall that was four feet away), plus other more serious complications like post-obstructive pulmonary edema. The medics and some nurses, though, treat naloxone like a solely punitive measure instead of a life-saving device.

poo poo, we get it as 0.4 mg up here in Canada. Even that'll wake someone way the hell up if they're down on morphine or hydromorphone or whatnot. Takes two or three vials to reverse a fentanyl shot though.

It's kind of funny seeing the number of people these days who come in saying they want to get on suboxone to get off the 'heroin.' So I test their urine, and without exception the 'heroin' is just fentanyl, as in it's the only opioid in their system. No carfentanil yet, thank God.

# ¿ May 14, 2017 01:06

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Rhandhali posted:

We transplant hepc livers now, they just get harvoni afterwards.

Haha, seriously? That seems... weird to me.

I could almost see transplanting HCV+ hearts, but one of the most common causes for needing a liver transplant is hep C. And even if it's not cirrhotic, your hepatoma risk is always elevated, even after viral clearance.

sea of losers posted:

levamisole doesnot improve the effects of cocaine, it simply is much harder to detect as a cut than flour or inositol or baking soda or w/e

Yeah, levamisole is white, widely available in Colombia (as a hog dewormer), cheap, and melts at roughly the same temperature as cocaine.

The fact that it causes acute-onset neutropenia is probably of secondary concern to the producer.

# ¿ May 27, 2017 06:10

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

HelloSailorSign posted:

I haven't thought about mouse or rat opioid usage for years (school, really), but I know that buprenorphine in mice is dosed about 0.03 mg/kg to 0.05 mg/kg (for HCl) or 0.6 mg/kg for the SR. How do you dose people with buprenorphine? I think mice need higher opioid doses for effect.

The dose range is generally 2-24 mg for sublingual buprenorphine. There is theoretically a 'ceiling effect' where basically all the opioid receptors are flush with bupe and any increase will have no effect, so unless you're doing something very specific like TID dosing for pain it's not dosed beyond that.

And if all the mice need higher opioid doses, then we should probably start using opioid-naive mice in studies :v:

# ¿ May 28, 2017 06:48

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

PT6A posted:

Safe injection sites, while helpful, are not enough because if you're forced to obtain the drugs illegally, they're still of an unknown strength, and expensive enough that you'll likely need to resort to bad things in order to obtain them.

Oh hey so there's some clinics in Vancouver that provide prescription heroin, as well as prescription hydromorphone, to be used in combination with safe injection sites. So the drugs are free, designed to be injected, and of known potency. The concept is frequently referred to as SIOAT (Supervised Injectable Opioid Agonist Therapy).

It may be starting up at some point in Alberta, but who the gently caress knows what'll happen if the UCP wins the election. My clinic wanted to look into this, but Alberta Health Services declined to provide funding and is trying to set up their own program.

# ¿ Dec 3, 2018 03:19

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

KingEup posted:

The US Department of Justice have released a statement on supervised injecting facilities:

The DOJ doesn't know what the gently caress it's talking about.

-Me, a actual doctor

# ¿ Dec 7, 2018 07:14

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Chinese business association seeks to quash exemption for safe injection sites

Oh my god gently caress offfffff

# ¿ Dec 12, 2018 07:36

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

Does anyone here have any experience (provider, patient, or other) with Sublocade, the injectable buprenorphine? Apparently it's coming down the pipeline in Canada and I know nothing about it.

# ¿ Jan 18, 2019 23:42

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

I'm going to the American Society of Addiction Medicine conference for my first time this year, and going through the course list like a third of the sessions are "How not to get arrested while prescribing opioids!" or something of that nature. We... do not have sessions like that at the Canadian version of this conference.

:lol:

and also what the gently caress, America.

Also the 'advanced' harm reduction sessions are mostly focused around buprenorphine. Suboxone's certainly my first choice, but are there really no safe injection sites in the US? To say nothing of prescription injectables?

# ¿ Apr 2, 2019 19:03

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

GreyjoyBastard posted:

your sentences seem to be full of words, and they're individually comprehensible, but ???

Sorry, I threw that up between patients and I think I spliced a couple of sentences together.

It's darkly hilarious that one of the lead themes at a conference dedicated to addiction medicine is "not getting indicted," because apparently the DEA is coming after doctors for doing their jobs.

The conference is promoting buprenorphine as 'advanced' harm reduction, when it's really very basic harm reduction. My city is setting up a prescribed injection opioid site (using hydromorphone, it's way easier to access than diamorphine), and my clinic has a safe injection site in the basement.

# ¿ Apr 3, 2019 15:11

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

pangstrom posted:

Thread's been dead for a year, I'm sure convo has moved to another one, but drat the latest fatal OD counts are brutal.

I'm losing about 4 patients a month to ODs (up here in Canada). I've lost patients I've known for years. Covid won't burn me out but this might

# ¿ Nov 18, 2021 20:34

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# ¿ May 13, 2024 21:17

Albino Squirrel: Apr 25, 2003; Miosis more like meiosis

PT6A posted:

As a fellow Canadian: what do we do about it?

Personally, as a layperson, I'm in favour of full legalization and safe/cheap supply.

I've had friends and family die from overdoses, and at the same time I've had friends who've been hosed around for legitimate pain relief waiting for a surgery the needed, to the point they made a scene and said "I don't give a gently caress anymore, if you're worried I'm abusing the pills, come and count my loving pills at 3AM any day of the week, count the pills if you're worried I'm a drug seeker, just give me the loving medication I need." He's since got the surgery and weaned off the painkillers, he said it was hell but better than continuing to take them, for what it's worth.

Alcoholics drink hand sanitizer if they can't get booze, opiate addicts do dangerous things if they can't get a supply. Harm reduction simply makes sense to me, because honestly I'd rather my cousin was dependent on opiates that he could get from a clinic or whatever... than loving dead, which he is, because he died from an overdose.

Safe supply is part of it, substantial expansion of safe consumption sites is part of it, and I'm personally a big fan of injectable opioid agonist therapy for patients who have tried and failed suboxone and methadone and continue to inject. It's funny, I'm usually trying to convince my chronic pain patients to severely limit their opioid use - because opioids do stop working as you become tolerant, and because opioids in general aren't particularly effective for most types of chronic pain - but the second someone tells me they've been injecting fentanyl my mind shifts and I'm all 'have all the opioids you need, my child.'

I find the issue isn't so much getting opioids into my patients these days - I mean, I provide a LOT of suboxone, and if you're only dealing with the physical dependence this is enough for most people to achieve sustained remission - but it's more that a) we have limited ability to deal with the underlying trauma that drives a lot of people to keep using, and b) we have an acute housing crisis which makes it very very hard for people to stabilize if they're more worried about where they're going to sleep tonight than how to work on their issues.

What we need isn't so much easy access to opioid dependence programs; we have those, I work at one, and we are very much low barrier. We need more general trauma-informed mental health supports, and we need major amounts of social housing because most people can't afford a place to live. But we'll never get the latter because :capitalism:

# ¿ Nov 20, 2021 00:00

The Something Awful Forums > Discussion > Debate & Discussion > The American Opioid Epidemic 20XX: Dropping the H-Bomb

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